SAS - HSE MESSAGE - LESSONS LEARNED (Note: Communicate the message to others)

Type o f Incident :

Exposure to Toxic Gases (H2S and Hydrocarbons)

Location o f Inc ident :

Corrosion Coupon Pit (Near Shah-1 Station) on Shah-Asab Oil Transfer Line (Mile 58).

Date & Time o f Incident :

03-02-2009 Approximately at 0735 Hrs.

Inc ident Description:

Four employees in Shah Field were exposed to H2S while draining a transfer line inside a corrosion coupon pit. The pit is approximately 12 feet deep (confined space).

Outcome:

Three fatalities and one serious injury. The injured person was air evacuated to hospital where he was treated, recovered and subsequently discharged from the hospital.

Immed ia te Causes:

Violation of Procedure (PTW & Confined Space Entry Certificate).

Breathing apparatus was not used and personal H2S detector was switched off.

Exposure to lethal concentration of H2S in confined space.

Root Causes:

Key root causes included:

Inadequate identification of job hazards.

Inadequate reinforcement of procedures.

Inadequate Identification of Training Needs.

Inadequate reinforcement of critical safe behavior.

Inadequate Guards &Warning Systems.

Lessons Learned:

Provide personal H2S detectors to all personnel including laborers/helpers working in H2S exposed areas.

Ensure all helper/laborers are fully trained for performing their assigned tasks.

Establish Access Control on all confined spaces with effective markings, signs & tagging; and locking, where applicable.

Ensure PTW is issued based on task risk assessment (TRA) and the high risk TRA has been endorsed by a safety professional (Safety & Loss Prevention Engineer (SLPE) as minimum).

Confined space entries cannot be made unless a SLPE has signed off the Confined Space Entry Certificate and he has reviewed the emergency plan

Include practical element (step test) and confined space entry in H2S/BA training course and for all operation/ production and HSE staff.

Empower laborers/workers to STOP unsafe activities and initiate contractual arrangements to protect/encourage individuals exercising ADCO STOP Policy.

Photograph o f Inc iden t Site:

For more details and information contact: Dr. M. R. Tayab HSE Advisor Tel: 00971 (0) 2 - 6042979 Cell: 00971 (0) 50- 3243996 Email: drtavab8adco.ae